Reversible visual deficit following debulking of a Rathke's cleft cyst: a tethered chiasm?

Case report

Restricted access

✓ Delayed chiasmal syndromes after emptying of a Rathke's cleft cyst have not been reported previously. When these deficits occur following the treatment of parasellar lesions they are usually associated with the descent of a scarred optic system into an empty sella, and vision often improves promptly when the optic system is elevated. Two months after transsphenoidal surgery with emptying of a large intrasellar cyst, a 22-year-old man developed recurrent bitemporal visual field deficits over a 3-day period. Sagittal magnetic resonance images demonstrated an enhancing band of tissue extending anteriorly from the normally placed chiasm down to the anterior portion of the sella turcica. At craniotomy the enhancing tissue was found to be scar extending from the anterior border of the chiasm to the diaphragma sellae. The anterior portion of the diaphragm was resected as widely as possible without dissecting the scar itself from the chiasm. A membrane consistent with the wall of a Rathke's cleft cyst was found attached to the resected tissue. The patient's vision was improved 2 days after surgery. This case illustrates that traction by scar extending from the chiasm to the diaphragm, even when the chiasm is in its normal anatomical location, may cause progressive visual loss; and that untethering of the chiasm by resecting the diaphragm while leaving the scar intact can result in improved vision.

Article Information

Address reprint requests to: Edwin G. Fischer, M.D., 110 Francis Street, Boston, Massachusetts 02215.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Midline magnetic resonance T1-weighted images with gadopentatate dimeglumine enhancement, sagittal projection. Left: Image obtained prior to the first operation. A homogeneous mass is seen expanding the sella (curved arrow) and extending into the suprasellar cistern (black arrows). The enhancement along the lesion's posterior aspect (open arrow) could represent scarring, displaced pituitary tissue, or tumor. Right: Image obtained before the second operation showing an enhancing band extending from the optic chiasm to the pituitary fossa (curved arrow) just anterior to the normally enhancing pituitary stalk (straight arrow).

  • View in gallery

    Charts of visual fields, left eye (left) and right eye (right). Upper: Findings on the morning of the second operation showing a temporal hemianopsia on the left and a superior quadrant temporal field defect on the right. Lower: Visual fields 2 months after resection of the diaphragma sellae.

  • View in gallery

    Photographs taken at the second operation. Left: The diaphragma sellae is incised between the optic nerves (closed arrows). Scar tissue (open arrow) can be seen attaching the chiasm to the diaphragm. Right: The diaphragm has been resected and scar tissue (open arrow) is still attached to the chiasm. The optic nerves are indicated by closed arrows.

  • View in gallery

    Photomicrograph showing tissue consistent with the lining of Rathke's cleft cyst. Note the variable thicknesses of epithelium with columnar cells on the luminal surface. H & E, × 40.

References

1.

Bergland RRay BS: The arterial supply of the human optic chiasm. J Neurosurg 31:3273341969Bergland R Ray BS: The arterial supply of the human optic chiasm. J Neurosurg 31:327–334 1969

2.

Decker RECarras R: Transsphenoidal chiasmapexy for correction of posthypophysectomy traction syndrome of optic chiasm. Case report. J Neurosurg 46:5275291977Decker RE Carras R: Transsphenoidal chiasmapexy for correction of posthypophysectomy traction syndrome of optic chiasm. Case report. J Neurosurg 46:527–529 1977

3.

Lee WMAdams JE: The empty sella syndrome. J Neurosurg 28:3513561968Lee WM Adams JE: The empty sella syndrome. J Neurosurg 28:351–356 1968

4.

Mortara RNorrell H: Consequences of a deficient sellar diaphragm. J Neurosurg 32:5655731970Mortara R Norrell H: Consequences of a deficient sellar diaphragm. J Neurosurg 32:565–573 1970

5.

Olson DRGuiot GDerome P: The symptomatic empty sella. Prevention and correction via the transsphenoidal approach. J Neurosurg 37:5335371972Olson DR Guiot G Derome P: The symptomatic empty sella. Prevention and correction via the transsphenoidal approach. J Neurosurg 37:533–537 1972

6.

Poppen JL: Discussion: symposium on pituitary tumors — IV. J Neurosurg 19:22251962Poppen JL: Discussion: symposium on pituitary tumors — IV. J Neurosurg 19:22–25 1962

7.

Scott RMSonntag VKHWilcox LMet al: Visual loss from optochiasmatic arachnoiditis after tuberculous meningitis. Case report. J Neurosurg 46:5245261977Scott RM Sonntag VKH Wilcox LM et al: Visual loss from optochiasmatic arachnoiditis after tuberculous meningitis. Case report. J Neurosurg 46:524–526 1977

8.

Tani SYamada SKnighton RS: Extensibility of the lumbar and sacral cord. Pathophysiology of the tethered spinal cord in cats. J Neurosurg 66:1161231987Tani S Yamada S Knighton RS: Extensibility of the lumbar and sacral cord. Pathophysiology of the tethered spinal cord in cats. J Neurosurg 66:116–123 1987

9.

Welch KStears JC: Chiasmapexy for the correction of traction on the optic nerves and chiasm associated with their descent into an empty sella turcica. Case report. J Neurosurg 35:7607641971Welch K Stears JC: Chiasmapexy for the correction of traction on the optic nerves and chiasm associated with their descent into an empty sella turcica. Case report. J Neurosurg 35:760–764 1971

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 222 222 46
Full Text Views 482 482 91
PDF Downloads 79 79 11
EPUB Downloads 0 0 0

PubMed

Google Scholar